Gastric epithelioid-cell granuloma in a paediatric patient with Crohn's disease.

To cite: Tominaga K, Kato M, Takahashi K, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-203229 DESCRIPTION A youth in his later teenage years was referred to our hospital with erythema nodosum in his lower extremities. He had previously received surgical treatment for an anal fistula at another hospital. The patient presented with weight loss and fever but had no abdominal pain, diarrhoea, bloody stools, no upper gastrointestinal symptoms and a faecal culture was negative. Ileocolonoscopy revealed longitudinal ulcers in the terminal ileum and multiple erosions from caecum to rectum. Crohn’s disease (CD) seemed the most likely cause and biopsy specimens demonstrated non-specific features of CD. Oesophagogastroduodenoscopy was performed in order to establish a diagnosis and to confirm the location and extent of the disease. Erosions were detected on the lesser curvature of the stomach body, the posterior wall of the stomach in the prepylorus region (figure 1) and on the duodenal bulb. A biopsy specimen from the prepylorus erosion identified an epithelioid-cell granuloma (figure 2), but focally enhanced gastritis was not detected. Helicobacter pylori infection was not present and non-steroidal anti-inflammatory drugs (NSAIDs) were not used. The biopsy specimens from the duodenal bulb erosions showed no focal cryptitis of the duodenum, which would indicate CD. Gastric erosion biopsies can be used to detect granulomas and may help in establishing a diagnosis of CD. A general consensus is lacking regarding a definition of what qualifies as significant gastric involvement in CD. This case may support the inclusion of gastric erosions without H pylori infection or NSAIDs use as an oesophagogastroduodenoscopy indicator of CD.